Sleep Assessment


Welcome to the Sleep Assessment! Please check off each statement that applies to you. Each is worth 1 point.

Name
Email

You always wake up too early in the morning

1 out of 24

You wake up frequently throughout the night to use the bathroom

2 out of 24

You have a hard time falling asleep

3 out of 24

It’s hard to get to sleep because you feel tense and can’t relax

4 out of 24

You wake up alert and ready to go between 2am and 4am and have a hard time getting back to sleep

5 out of 24

You cannot get to sleep due to constant ruminations and negative thought loops

6 out of 24

You seldom or never remember your dreams

7 out of 24

You’re a night-owl and like to stay up late

8 out of 24

You have frequent nightmares

9 out of 24

You are driven and energetic even though you sleep little

10 out of 24

You’ve had sleep problems since a prolonged period of stress or a single highly stressful event

11 out of 24

You are unable to quit using caffeine

12 out of 24

You have restless leg syndrome

13 out of 24

You have leg cramps

14 out of 24

Chronic pain when you are lying down keeps you from sleeping well

15 out of 24

Your children’s insomnia keeps you from sleeping

16 out of 24

You frequently need tranquilizers like Xanax, Ativan, and Valium to get to sleep

17 out of 24

You frequently need Trazadone or Vicodin to help you sleep

18 out of 24

You frequently use diphenhydramine (Sleepinal or Dramamine) over-the –counter medication

19 out of 24

You need alcohol to sleep

20 out of 24

You have sleep apnea

21 out of 24

You use your phone, tablet, or computer after 7 PM

22 out of 24

You have bright indoor lighting

23 out of 24

Your pets sleep with you

24 out of 24